These are the chief concerns of the president of the Southern African HIV Clinicians Society, Dr Francois Venter, who said the move by Health Minister Dr Aaron Motsoaledi last month showed much-wanted leadership.

Until last month people were only tested for HIV if they expressly asked for the test ('opt-in'), a strongly human rights-based approach that gave greater initiative to the individual but with potent negative implications for containing the pandemic.

'The fact that nearly half of all South Africans now know their HIV status* is a huge step forward from even 18 months ago and this new move will boost that further, but I'm worried that we're still not getting people to enter the system earlier,' said Venter.

He explained that in spite of the examples being set by some top-performing clinics and hospitals (Esselen Street clinic in Hillbrow tests on average 4 000 people per month) 'we're still getting people coming in very late when it's harder to turn them around'.

One major reason for this was the health care system not being friendly enough for people to come forward for testing while they were still healthy.

Venter added, 'we need to create a system where people are willing to present when their CD4 cell counts are 500 or even 200, but even community-based testing has not had the huge impact we hoped for; it's very interesting but disturbing'.

Unless the health authorities made the linkages between testing positive, obtaining a CD4 cell count and 'finally' getting onto the ARV service, a boost of HIV status knowledge among the population would count for little.

SANAC vice-chair waves red flag

Cautions have been expressed about opt-out testing by Mark Heywood, vice-chairperson of the South African National AIDS Council (SANAC), who said HIV diagnosis remains 'full of dangers', while access to treatment is still far from guaranteed. His concerns lie at the core of what has been an intense and prolonged debate around the two approaches with eloquent arguments for opt-out by, among others, AIDS activist Justice Edwin Cameron who cites tragic, unnecessary deaths of close friends in making his case. Heywood accuses Cameron of trying to 'de-exceptionalise when HIV remains an exception'. Cameron and many clinicians argue that the disease is now as treatable as several other high-profile ones.

Venter weighed in with 'sometimes I think that some non-clinicians think you can defer this forever. At what point do you say, 'It's all OK, you can start this process'?

He shared Heywood's concerns but said 'waiting for the perfect system' would do more harm than good. 'He [Heywood] is worried that people are still scared. Where I disagree with him is that at some point you still need to get tested. We must do our best to ensure that the testing systems are safe and confidential and as helpful as possible. I don't believe it will ever not be a scary process for anyone - but we must support and walk the path with them.'

Venter said that to make this concrete he had made it his mission whenever visiting a casualty department in the public sector to ask how many HIV counselling rooms they had. 'I don't think anyone has given thought to the dire need to go around the country and work out what opt-out means in terms of resources,' he added.

Real support = doing the maths

'Even if you don't counsel you have to give someone the results confidentially and hand them a referral note, so a private room is essential,' he explained. Venter gave the example of a small but busy casualty seeing 100 people per day, 'all sick with some shortterm thing'. 'Now you want to get all 100 HIV tested. With each counsellor seeing 20 people per day, you need at least five rooms.' Somebody needs to sit down and apply their minds to 'the practicality and costs of it'.

Repairing, altering or adding to some 3 500 public health care facilities and employing an estimated extra 30 000 people (for counselling), was a major resource-intensive operation that went well beyond public announcements. Venter rejected calls in some quarters for compulsory HIV testing. 'I must confess I leaned towards this at one stage but the stuff I took for granted didn't come into being and I had to rethink hard.

There's no room for compulsory testing. It's wrong and we have to fix the system before we start doing radical things.'

A change to South Africa's HIV testing policy was advocated as far back as December 20061 (HIV clinicians Professors Linda-Gail Bekker and Robin Wood arguing for opt-out in the SAMJ Forum section). Fellow clinicians, Dr Harry Moultrie and Professor Nigel Rollins (universities of the Witwatersrand and KwaZulu-Natal medical schools, respectively), warned at the July 2007 AIDS conference in Durban that unless mandatory HIV testing of all children was introduced at their 6-week immunisation visit and testing of pregnant women was doubled, South Africa faced an 'unstoppable wave of child mortality'.2